Provider Demographics
NPI:1952550485
Name:DOROTHY M. MUNCH, D.O., LLC
Entity Type:Organization
Organization Name:DOROTHY M. MUNCH, D.O., LLC
Other - Org Name:POPLAR BLUFF WELLNESS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCALISTER
Authorized Official - Suffix:
Authorized Official - Credentials:BSHA/LTC
Authorized Official - Phone:573-778-1697
Mailing Address - Street 1:930 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-4242
Mailing Address - Country:US
Mailing Address - Phone:573-778-1620
Mailing Address - Fax:573-778-1486
Practice Address - Street 1:930 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-4242
Practice Address - Country:US
Practice Address - Phone:573-778-1620
Practice Address - Fax:573-778-1486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36720207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO164653OtherBLUE CROSS BLUE SHIELD
MO242613084Medicaid
MO26D1003101OtherCLIA
MO000000E14668OtherPREMIER BENEFITS
915331OtherUNITED HEALTH CARE
MOP00109903OtherMEDICARE RAILROAD
MO1922003276OtherINDIVIDUAL NPI
MO242613073Medicaid
MOE14668Medicare UPIN
MO164653OtherBLUE CROSS BLUE SHIELD